74 year-old female with a history of hypertension controlled by medication, PE now on Eliquis, appendectomy, COPD presented to standalone ED at 0500 with low back pain, abdominal pain, chest pain. Pain began after witnessing her granddaughter have a seizure about seven hours prior and has been persistent. CT revealed evidence of acute left sided renal infarct. BP is elevated at 193/101 upon admission. INR 1.9, PTT 35.0. Heparin drip was initiated at 15ml/hr per weight-based protocol. She was transferred to a hospital-based ED for further workup, arriving at 11:15. While in the ED, her blood pressure remained high and untreated. She was given IV medication for pain, with the last dose (50 mcg Fentanyl) administered at 11:40. At 13:00 she complained of intractable headache and dizziness. At 15:30 a rapid response was called due to unresponsiveness. A stroke alert was initiated. BP 202/106. Heparin was discontinued due to concern for bleeding. She was immediately taken to CT which revealed a massive bilateral posterior bleed involving occipital and parietal lobes, with presumed or impending herniation. She was intubated and admitted to the ICU. She was terminally extubated two days later.
Our questions are focused on the appropriateness of heparin in this scenario.
• Should hematology have been consulted prior to heparin initiation?
• Was heparin reasonable in the setting of a renal infarct in a patient already on Eliquis?
• Should there have been blood pressure parameters given heparin administration?
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No questions yet!
Do you believe there might have been medical error?
1. Hematology or vascular medicine referral will be helpful 2. This is the part which is gross deviation of SOC. Hearin is not reasonable, as the patient is on Eliquis and has an INR of 1.9 and a PTT of 35. Guidelines emphasize anticoagulation as a mainstay for renal infarction, but adding heparin to an existing DOAC, such as apixaban, significantly increases bleeding risk without evidence-based benefit. Instead, the approach should involve verifying apixaban adherence, dosing appropriateness, and potential switch to another agent if therapeutic failure is confirmed— not supplementation. Renal infarction in this context may represent inadequate anticoagulation intensity or non-adherence rather than a need for dual therapy. Here, the primary step is to get the BP down and not anticoagulation
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Blood pressure parameters should have been established and actively managed during heparin administration, especially in a high-risk patient with elevated BP (193/101 on admission, rising to 202/106). Uncontrolled hypertension is a known risk factor for bleeding complications with anticoagulation, and while specific thresholds for heparin initiation vary (e.g., BP ≥230/120 is often cited as a contraindication for increased bleeding risk), guidelines recommend monitoring and controlling BP to mitigate hemorrhage risk. In this scenario, with persistent hypertension untreated in the ED and subsequent intracranial bleed, BP goals (e.g., <180/100 or similar, adapted from stroke protocols) would have been prudent to balance thrombotic and bleeding risks
What makes you a good expert for this case?
I have testified in 10 trials and done 9 depositions. This is a clear case of gross deviation.
How often do you encounter cases similar to this one in your practice?
It does come on occasion. We definitely have clear protocols with heparin to mitigate the hypertension and BP control.
Do you believe there might have been medical error?
This is a difficult case. Here are some of my thoughts. 1) Generally, one would not prescribe a full dose of heparin to a patient already anticoagulated on Eliquis. I would want to know when the patient's last dose of Eliquis was. If 48 hours ago, its effect have been largely worn off by the time she was admitted. However, if she took a dose the evening before, and particularly if she received a dose the morning she was hospitalized, it was still active and she was double anticoagulated. 2) It would be very important is she was also on aspirin or clopidogrel. 3) Her INR was 1.9 which is abnormal and indicates perhaps another coagulopathy in addition to the Eliquis. Did she have DIC? A hematology consult would have been very helpful to sort this out. I'd like to know if she had any thrombocytopenia at the time the heparin was started. 4) It is important to know what her creatinine was given her history of hypertension and her renal infarct, since Eliquis is excreted by the kidneys and there is risk to giving it to those with renal insufficiency. Was she on a full dose? 5) The uncontrolled hypertension in someone on double (or triple) anticoagulation increased her risk of intracranial hemorrhage. It should have been controlled prior to full anticoagulation with heparin. It would take some research to come up with an exact parameter.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Explained above. Potential double anticoagulation with Eliquis and heparin. Potential decreased excretion of Eliquis given the renal infarct and possible chronic renal insufficiency from HTN. Also INR of 1.9 show evidence of abnormal clotting at the time heparin was started. All of this indicates that the anticoagulation more likely than not precipitated the intracranial hemorrhage. Intracranial hemorrhage can occur even in patients appropriately anticoagulated on one medication.
What makes you a good expert for this case?
I have been a hematologist for 35 years. I have taken care of many high-risk individuals and many patients on anti-coagulation. I have reviewed a number of coagulation cases in my expert witness practice.
How often do you encounter cases similar to this one in your practice?
I will be honest, not often. This is a very unique case.
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